The AHRQ PSNet Collection comprises an extensive selection of resources relevant to the patient safety community. These resources come in a variety of formats, including literature, research, tools, and Web sites. Resources are identified using the National Library of Medicine’s Medline database, various news and content aggregators, and the expertise of the AHRQ PSNet editorial and technical teams.
van Dalen ASHM, Jung JJ, Nieveen van Dijkum EJM, et al. J Patient Saf. 2022;18:617-623.
Leveraging lessons learned in aviation, patient safety researchers have begun exploring the use of medical data recorders (i.e., “black boxes”) to identify errors and threats to patient safety. This cross-sectional study found that a medical data recorder identified an average of 53 safety threats or resilience support events among 35 standard laparoscopic procedures. These events primarily involved communication failures, poor teamwork, and situational awareness failures.
Doorey AJ, Turi ZG, Lazzara EH, et al. Catheter Cardiovasc Interv. 2022;99:1953-1962.
Closed loop communication (CLC) ensures a clear transfer of information by having the recipient repeat the order for verification. In this study, procedures in the cardiac catheterization lab were observed to assess the frequency and accuracy of CLC. Despite three interventions over five years (education, on-going feedback, accountability), CLC remained suboptimal, with both incomplete orders given and incomplete responses.
Combs CA, Einerson BD, Toner LE. Am J Obstet Gynecol. 2021;225:b43-b49.
Maternal and newborn safety is challenged during cesarean delivery due to the complexities of the practice. This guideline recommends specific checklist elements to direct coordination and communication between the two teams engaged in cesarean deliveries. The guideline provides a sample checklist and steps for its implementation.
A 55-year old man was admitted to the hospital for pneumonia requiring intravenous antibiotics. After three intravenous lines infiltrated, the attending physician on call gave a verbal order to have a percutaneous intravenous central venous catheter placed by interventional radiology the next morning. However, the nurse on duty incorrectly entered an order for a tunneled dialysis catheter, and the radiologist then inserted the wrong type of catheter. The commentary explores safety issues with verbal orders and interventional radiology procedures.
In this retrospective review of root cause analysis (RCA) reports of select gastrointestinal procedures, researchers identified 27 adverse events 30-month period. Nearly half (48%) of events caused major or catastrophic harm. The most frequently reported adverse events were attributable to human factors (22%), medication errors (22%) or retained items; retained items were associated with the most harm.
Clear and high-quality communication between all staff involved in caring for a patient is essential in order to achieve situational awareness. Breakdowns in communication are closely tied to preventable adverse events in hospitalized and ambulatory patients.
The Joint Commission and National Quality Forum both consider wrong-site, wrong-procedure, and wrong-patient surgeries to be never events. Despite improvement approaches ranging from the Universal Protocol to nonpayment for the procedures themselves and any consequent care, these serious surgical errors continue to occur. This study measured the incidence of incorrect surgeries in Veterans Health Administration medical centers from 2010 to 2017. Surgical patient safety events resulting in harm were rare and declined by more than two-thirds from 2000 to 2017. Dentistry, ophthalmology, and neurosurgery had the highest incidence of in–operating room adverse events. Root cause analysis revealed that 29% of events could have been prevented with a correctly performed time-out. A WebM&M commentary examined an incident involving a wrong-side surgery.
Gilmartin HM, Langner P, Gokhale M, et al. J Nurs Care Qual. 2018;33:53-60.
In a robust safety culture, nurses and other health care workers feel comfortable reporting safety hazards without fear of repercussions. This study found no relationship between nurse-reported psychological safety and adherence to a central line insertion checklist in the Veterans Affairs system. A recent PSNet interview with Linda Aiken discussed what investments in the nursing workforce yield the biggest safety impacts.
Yorkgitis BK, Brat GA. Am J Surg. 2018;215:707-711.
Use of mnemonics to recall standardized steps can help augment reliability. This review discusses the development of the RIGHTT mnemonic (Risk for adverse event, Insight into pain, Going over pain plan, Halting opioids, Tossing unused opioids and Trouble identification) designed to help surgeons improve safety of opioid prescribing for surgical pain.
Douglass AM, Elder J, Watson R, et al. Ann Emerg Med. 2018;71:74-82.e1.
The use of double checks by two nurses is a strategy to minimize the risk of medication administration error. This randomized controlled trial investigated the effectiveness of double checks in a simulated patient care scenario. The investigators found that double checking did increase rates of error identification compared to single checking, but many errors still went undetected. A prior qualitative study found that double checking is often variably implemented, with clinicians having differing perceptions on how to perform the process effectively.
ISMP Medication Safety Alert! Acute Care Edition. May 18, 2017;22:1-4.
Verbal orders are known to increase risk of error in care. This newsletter article summarizes survey results that sought to characterize current verbal order behaviors. Notably, practices to improve the reliability of verbal orders such as read backs were not optimally integrated in medication processes. The article includes recommendations for organizations, individuals, and teams to improve the safety of verbal orders.
A woman with a history of chronic obstructive pulmonary disease underwent hip surgery and experienced shortness of breath postoperatively. A chest radiograph showed a pneumothorax, but the radiologist was unable to locate the first call physician to page about this critical finding.
Miller S, Lattanzio M, Cohen S. Nursing (Brux). 2016;46:63-4.
The teach-back method, having patients repeat instructions to confirm they understand discharge information, can help enable safe postdischarge care. This commentary describes an initiative that embedded teach-back into standard nursing activities and resulted in reduced readmissions.
A man with a history of poorly controlled diabetes and pancreatic insufficiency was found unresponsive. Paramedics transported him to the emergency department, where a resident placed a right internal jugular line for access but was unable to confirm placement. The resident pulled the line, opened a second line insertion kit, started over, and confirmed placement with ultrasound. The patient went into cardiac arrest, and a chest radiograph noted a retained guidewire in the pulmonary artery.
During laparoscopic subtotal colon resection for adenocarcinoma, a patient's bladder was accidentally lacerated and surgeons repaired it without difficulty. As nurses set up bladder irrigation equipment, no one noticed the bag of solution was dripping into the power supply of an anesthesiology monitor. Suddenly sparks and flames began shooting from the monitor, and the OR filled with black smoke. Fortunately, the fire was extinguished quickly and neither the patient nor any OR staff was injured.
Clarke JR. PA-PSRS Patient Saf Advis. 2015;12:19-27.
Wrong-site surgeries are considered never events by the National Quality Forum and sentinel events by The Joint Commission. Drawing from data submitted to the Pennsylvania Patient Safety Authority, this article analyzes 83 wrong-site extremity procedures in orthopedic surgery reported over 9 years and recommends site marking and time outs as strategies to prevent these incidents.
A man with suspected renal cell carcinoma seen on CT in the right kidney was transferred to another hospital for surgical management. The imaging was not sent with him, but hospital records, which incorrectly documented the tumor as being on the left side—were. The second hospital did not obtain repeat imaging, and the surgeon did not see the original CT prior to removing the wrong kidney.
Boyd M, Cumin D, Lombard B, et al. BMJ Qual Saf. 2014;23:989-93.
Read-backs are widely recommended in order to improve communication of critical clinical information. This simulation study found that anesthesiologists who immediately read back clinical data during simulated emergencies were eight times more likely to retain and use the information appropriately.
Wakefield DS, Wakefield BJ, Despins L, et al. Jt Comm J Qual Patient Saf. 2012;38:24-33.
Verbal orders, usually for medications, are commonly used in the inpatient setting despite being a recognized source of error. This survey of 40 hospitals found wide variation in hospital policies regarding verbal orders, with no uniform standard on which providers were allowed to give or receive verbal orders and varying approaches to documenting these orders. Although specific methods, such as read-backs, are endorsed for improving the reliability of verbal orders, few hospitals specifically mandated the use of these communication tools. A case of a misunderstood verbal order that led to a serious error is discussed in this AHRQ WebM&M commentary.
Ali M, Osborne A, Bethune R, et al. J Patient Saf. 2011;7:139-143.
Preoperative team briefings, or time outs, are now considered mandatory in operating rooms. These briefings, which may be structured around a formal checklist, are intended to create shared situational awareness and thereby avert serious errors such as wrong-site surgery. Resistance to implementing preoperative briefings has been encountered on the grounds that operating room efficiency may be harmed. However, this study conducted at two British hospitals found that operating room start times were not delayed after briefings were standardized, and operating room personnel strongly felt the briefings improved safety. A prior study also found that briefings actually improved operating room efficiency by preventing unexpected procedural delays.
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